Provider Demographics
NPI:1427400993
Name:AL KHOURY, BASHAR
Entity type:Individual
Prefix:
First Name:BASHAR
Middle Name:
Last Name:AL KHOURY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 17TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5351
Mailing Address - Country:US
Mailing Address - Phone:309-779-3101
Mailing Address - Fax:309-779-3105
Practice Address - Street 1:2701 17TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201
Practice Address - Country:US
Practice Address - Phone:309-779-3101
Practice Address - Fax:309-779-3105
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-08
Last Update Date:2019-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-149076208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist